Adnexal Torsion in Children and Adolescents: A Retrospective Review of 245 Cases at a Single Institution

Study Objective

Adnexal torsion (AT) requires urgent surgical intervention to preserve ovarian function. Historically, treatment for AT was oophorectomy because of concerns related to leaving a nonviable ischemic ovary. No published studies support these theoretical concerns and current literature supports conservative management. The aim of this study was to review the institutional outcomes for AT cases, including salvage rates and complications.

Safety and Feasibility of a Single-port Laparoscopic Adnexal Surgery During Pregnancy

Study ObjectiveTo evaluate the safety and feasibility of single-port laparoscopic adnexal surgery during pregnancy.DesignA retrospective study (Canadian Task Force Classification III).SettingA university hospital.PatientsA total of 14 women with intrauterine pregnancy who underwent single-port laparoscopic surgery (SPLS).InterventionWe retrospectively reviewed the medical records of 14 women with intrauterine pregnancy who underwent SPLS between November 2009 and September 2012 for the treatment of an adnexal mass.Measurements and Main ResultsFactors investigated included the duration of surgery, differences between preoperative and postoperative hemoglobin, the size of the mass as measured by ultrasonography, major intraoperative or postoperative complications, conversion to multiport laparoscopy, and pregnancy outcomes. Single-port laparoscopic adnexal surgery was successfully performed in all 14 pregnant patients with an adnexal mass. The median gestational age at operation was 9 weeks (range, 4 weeks–17 weeks 4 days). Procedures included ovarian cystectomy with or without detorsion (n = 9), cyst aspiration with detorsion (n = 2), salpingectomy (n = 2), and salpingostomy (n = 1). The median duration of surgery was 59 minutes (range, 36–84 minutes). No major intraoperative or postoperative complications were encountered, and there was no need for conversion to multiport laparoscopic surgery. Five women had spontaneous vaginal delivery, and 5 women underwent cesarean delivery at term. One woman had preterm delivery at a gestational age of 24 weeks 5 days. In 1 case, abortion occurred 2 weeks after the operation.ConclusionBased on these initial findings, SPLS appears to be a safe and technically feasible treatment for an adnexal mass during pregnancy.     

腹腔镜手术治疗儿童腹痛伴附件包块14例临床分析

目的：探讨腹腔镜手术在治疗儿童腹痛伴附件包块的应用和安全性。方法：回顾性分析因腹痛伴附件包块行腹腔镜治疗的14例患儿(年龄≤14岁)的临床资料。结果：平均年龄11．7岁(8～14岁),7例行患侧附件切除(包括2例同时切除阑尾),3例切除患侧输卵管,4例卵巢囊肿剥除。病理类型成熟性畸胎瘤8例(5例肿瘤扭转已出血梗死),出血坏死变性组织5例(包括2例输卵管系膜囊肿扭转和1例输卵管扭转),卵巢无性细胞瘤1例。手术均顺利进行,无一例发生手术和麻醉并发症。术后平均随访21．7月(1～83月),无一例再次出现附件包块,不影响患儿月经。结论：腹腔镜手术治疗儿童腹痛伴附件包块是安全和可行的。     

Adnexal Torsion

Adnexal torsion is an uncommon gynecologic disorder caused by the partial or complete rotation of the ovary and/or the fallopian tube on its vascular support. Delay in treatment can impact fertility adversely. The objective of this report is to provide clinical recommendations based on the latest evidence. Specifically we discuss epidemiology, clinical presentation, diagnostic approach and management of adnexal torsion in adolescents.     

Effect of Surgical Specialty on Management of Adnexal Masses in Children and Adolescents: An 8-Year Single-Center Review

Study ObjectiveChildren with adnexal masses might be managed by pediatric surgeons, urologists or gynecologists, with the potential for different management strategies between specialties. In this study we compared ovarian conservation rates and surgical approach for adnexal masses in children and adolescents managed either by pediatric surgeons/urologists or gynecologists at a tertiary care institution.DesignRetrospective cohort review.SettingTertiary pediatric and adult university hospital.ParticipantsPatients younger than 18 years of age with an adnexal mass managed surgically with removal of histologically confirmed ovarian or fallopian tube tissue from 2008 to 2015.InterventionsLaparoscopic or open procedure for adnexal mass.Main Outcome MeasuresThe primary outcome was rate of ovarian conservation relative to surgical specialty. The secondary outcome was surgical approach relative to surgical specialty.ResultsForty-eight patients underwent surgery for adnexal masses; 26 (54%) under pediatric surgery/urology and 22 (46%) under gynecology care. Laparoscopy was performed in 5 (19%) pediatric and 19 (86%) gynecology cases (P = .000006). Of 24 patients older than 12 years of age with a benign tumor, 10 (42%) underwent procedures resulting in loss of an ovary with or without fallopian tube; 8 of these (80%) were under pediatric care. Of the remaining 14 (58%) who underwent ovarian conserving surgery, 12 (80%) were under gynecology care (P = .0027).ConclusionPatients with a benign tumor were significantly more likely to undergo ovary-preserving surgery under gynecology care than under pediatric surgery/urology care. A multidisciplinary team approach involving gynecology and pediatric surgical specialties would be valuable in assessing the merits of ablative or conservative surgery in each case.     

Laparoscopy in pregnancy and the pediatric patient

Minimally invasive surgery is now standard of care for many procedures in pediatric gynecology. Laparoscopy has been well documented to produce faster recovery,decreased postoperative pain, and because of smaller incisions, a better cosmetic result. These are important when considering an active pediatric patient. Although a laparoscopic approach to endometriosis, adnexal masses, and ovarian torsion are well supported in the literature in the pediatric patient, more data are needed with regard to SILS in younger patients. Laparoscopy seems to be a better approach to oopheropexy in children undergoing radiation, and in resection of certain mullerian anomalies; however, the numbers are low.Similarly in pregnant patients, laparoscopy provides for shorter recovery times,decrease analgesic use and shorter hospital stays. Concerns about poor fetal outcomes in surgery during pregnancy for non gynecologic problems have been brought to light; however, the evidence indicates that these outcomes can be attributed to the nature of the underlying disease and not the surgical approach. With regard to pneumoperitoneum the effect of CO2 insufflation on fetal physiology and long-term outcomes remains unclear, and will continue to be an issue of controversy until larger studies are published.With both the pediatric and pregnant populations, laparoscopic complications can be diminished when performed by skilled surgeons with strict adherence to good technical principles. The advantages of laparoscopy are great, and this approach should be considered in pediatric and pregnant patients.     

Adnexal masses in adolescent girls with pelvic pain: Report on 63 cases

To improve clinical appreciation of these lesions, we reviewed the presentation, evaluation, outcome, and therapeutic aspects of painful adnexal masses in adolescent females. During the period January 2005–September 2006, 63 adolescent females with painful adnexal masses were recruited. The patient management and outcomes were documented. The mean age was 15.36 ± 1.6 years, and the mean diameter of the masses was 54.5 ± 1.3 mm. Forty-nine patients (77.7%) underwent surgical management, and 45 of the 49 surgeries were achieved by laparoscopic surgery (91.8%). Two converting laparotomies (4%) were performed. Fourteen patients with a presumed functional cyst were followed up without surgery. Postoperative histopathologic evaluation revealed a benign epithelial ovarian cyst rate of 26.5%, a mature cystic teratoma rate of 22.4%, and a borderline ovarian tumor rate of 4.08%. Non-neoplastic adnexal lesions were encountered in surgeries of 22 cases. The incidence of acute ovarian torsion and true ovarian neoplasm was 9.52% and 55.1%, respectively, and none was malignant. True ovarian neoplasia remains a common indication for surgery in the majority of adolescents. Because most cases are benign, minimal access surgery should be performed whenever feasible.     

子宫内膜异位症合并不孕患者腹腔镜术后药物治疗妊娠结局分析

目的:探讨子宫内膜异位症(EMT)合并不孕患者腹腔镜术后联合药物治疗对妊娠结局的影响。方法:回顾性分析2006年1月至2011年6月在北京朝阳医院妇产科行腹腔镜手术且随访资料完整的230例EMT合并不孕患者的临床资料,采用方差分析EMT术前r-AFS分期(Ⅰ~Ⅳ期)与术后是否行药物治疗(孕三烯酮组、GnRHa组与未用药组)对各种妊娠结局及不同性质的妊娠结局(良好结局与不良结局)的影响。结果:1术后妊娠135例,妊娠率为58.7%。230例患者中术前4种r-AFS分期的妊娠率比较,差异无统计学意义(P0.05)。135例妊娠患者术前4种r-AFS分期间不同妊娠结局的比较,差异无统计学意义(P0.05)。有妊娠结局的126例患者术前4种r-AFS分期在良好或不良妊娠结局之间比较,差异无统计学意义(P0.05)。2230例患者中,GnRHa组与孕三烯酮组、未用药组相比,其发生的不同妊娠结局比较,差异有统计学意义(P0.05)。有妊娠结局的患者中GnRHa组与未用药组相比,良好结局与不良结局的比较,差异有统计学意义(P0.05),而孕三烯酮组与未用药组相比,差异无统计学意义(P0.05)。结论:术前r-AFS分期对于腹腔镜术后妊娠率及妊娠结局无影响。术后使用GnRHa对于导致不同的妊娠结局有一定的影响,对良好妊娠结局的影响有作用,而孕三烯酮作用不明显。     

Creation of a Composite Score to Predict Adnexal Torsion in Children and Adolescents

Study Objective

To create a composite score to predict adnexal torsion in children and adolescents.

A Preoperative Scoring System for Adnexal Mass in Children and Adolescents to Preserve Their Future Fertility

Study Objective

To develop a predictive score for ovarian malignancy to avoid unnecessary adnexectomy in cases of adnexal mass in pediatric and adolescent girls.

Single port transumbilical laparoscopic surgery for adnexal lesions: a single center experience in Korea

Objectives

The purpose of this study was to demonstrate the feasibility of single port transumbilical laparoscopic surgery (SPLS) for the treatment of adnexal lesions.

Methods

We have performed SPLS to treat adnexal lesions using a single three-channel port system with a wound retractor and surgical glove since October 2008. All patients who underwent SPLS for adnexal lesions between October 2008 and September 2009 were included in the study. We retrospectively reviewed their medical records and analyzed demographic data and surgical outcomes including age, medico-surgical illness, surgical indications, operative times and pathologic results.

Results

Eighty-six patients underwent SPLS for adnexal lesions. The median age of the patients was 31 years (range 14-78 years), the median body mass index was 21.0 kg/m² (range 16.7-32.2 kg/m²), and the median operation time was 64.5 min (range 21-176 min). The median blood loss was 10 ml (range 10-300 ml). The median length of postoperative hospital stay was 2 days (range 1-7 days). Endometriosis was the most frequently diagnosed etiology (34.9%). Other laparoscopic approaches were employed in two cases (2.3%). There were four cases (4.7%) with complications: three with pelvic infections and one with postoperative hemorrhage.

Conclusions

SPLS is a feasible approach for the treatment of adnexal lesions.     

妇科腹腔镜手术73例并发症的临床分析

目的:探讨妇科腹腔镜手术并发症发生的常见类型、处理及预防.方法:对我院1996年1月至2008年12月进行的8279例妇科腹腔镜手术的临床资料作回顾性分析.结果:腹腔镜手术并发症的发生率为0.88%(73/8279),腹腔内出血5例,榆尿管损伤5例,腹壁血管损伤20例,胃损伤1例,膀胱损伤1例,继发性腹腔妊娠1例,感染1例,切口疝1例,会阴部气肿10例,切口愈合不良25例.宫腹腔镜联合手术组的并发症发生率和附件手术组比较,差异无统计学意义(P>0.05),子宫肌瘤剥除术组及腹腔镜辅助阴式全子宫切除术组并发症的发生率与附件手术组相比,差异有高度统计学意义(P<0.01).结论:妇科腹腔镜手术并发症与手术难度和施术者技巧有关,应该严格按规范仔细操作、避免过度自信,降低并发症的发生率.     

异位妊娠腹腔镜手术及引流的选择

目的 :总结腹腔镜治疗异位妊娠术式及放置引流的选择。方法 :异位妊娠患者 6 3例 ,其中 32例在腹腔镜下行输卵管线形切开取胚术 ,另 31例行输卵管切除术。按引流的方式不同分为 3个小组 ,分别给予直径 10mm单腔管引流、5mm引流袋管引流和不放引流。术后统计手术时间、术后住院日、引流量、拔除引流管时间、体温、疼痛感、肛门排气时间和穿刺孔渗液的情况。结果 :切除组手术时间平均为 30分钟 ,术后平均住院时间 3天 ,引流量平均 10 0± 80ml,拔除引流管时间平均 12± 10小时 ;而取胚组则分别为 5 0分钟 ,4 .5天、2 0 0± 15 0ml、2 0± 12小时。切除组仅 2例未放置引流管者出现穿刺孔渗液 ,取胚组未放引流管者术后 36小时均有穿刺孔渗液 ,放置单腔管引流者 ,穿刺孔渗液发生率明显低于引流袋管引流者。结论 :异位妊娠腹腔镜手术治疗具有安全、微创、快捷的特点。无再生育要求者 ,最好行输卵管切除 ,此术式腹腔渗出不多。若要保留生育功能而行线形切开取胚术者 ,应置管充分引流。     

Laparoscopic management of mature cystic teratoma of bilateral ovaries with adnexal torsion occurring in a 9-year-old premenarchal girl

BACKGROUND: Laparoscopic surgery is a minimal-access procedure with many advantages. However, reports of young girls with adnexal disease treated by laparoscopic surgery are limited in the literature. CASE: A 9-yr-old premenarchal girl presenting with acute abdomen was treated by emergency laparoscopic surgery. Bilateral adnexal torsion was noted. After detorsion, bilateral cystectomy was successfully performed and ovarian tissues were preserved. Pathological diagnosis was mature cystic teratoma of bilateral ovaries. CONCLUSION: Although adnexal torsion occurring in a premenarchal girl is an extremely rare disorder and bilateral adnexal torsion is even more rare, gynecologists should possess sufficient knowledge about the manifestations of such disorder for immediate diagnosis and treatment to preserve future fertility and, if available, laparoscopic approach should be chosen for a young girl.     

妇科腹腔镜手术的临床进展

妇科腹腔镜手术近年来发展迅速,有损伤小、术后痛苦少、住院时间短、机体恢复快、美容效果好、医疗负担轻等优点。在妇科恶性肿瘤的诊治上,相对传统开腹手术,腹腔镜有自己独特的优势。随着手术器械设备的更新,医生经验的积累和技能的成熟,术中保护措施的研发,腹腔镜手术的并发症明显减少,安全性大大提高,临床运用范围愈加广泛。如今在传统腹腔镜手术的基础上又开发了微型腹腔镜手术,无气腹腹腔镜手术,机器人手术等新的手术方式。其各具特点,各有临床发展的潜力。就妇科腹腔镜手术近年来临床实践探索的新进展做综述。     

Successful Laparoscopic Surgery without Neuromuscular Blockade in a Patient with Malignant Hyperthermia Susceptibility

Malignant hyperthermia (MH) is a life-threatening clinical syndrome of hypermetabolism involving skeletal muscle. Susceptibility to MH is inherited in an autosomal dominant manner. Its common trigger is exposure to volatile anesthetic agents or depolarizing muscle relaxants. Deep neuromuscular blockade using muscle relaxants can improve the quality of surgical conditions and prevent cardiorespiratory adverse events during laparoscopic surgery. Here we report a case of successful laparoscopic surgery under anesthetic management without neuromuscular blockade in an MH-susceptible patient. A 22-year-old woman with a family history of MH underwent laparoscopic excision of ovarian endometrioma under total intravenous anesthesia and a posterior transversus abdominis plane block. The surgery was completed uneventfully. Our experience suggests that this type of anesthetic management is useful when performing laparoscopic surgery in MH-susceptible patients.     

腹腔镜手术治疗卵巢囊肿蒂扭转43例临床分析

目的:探讨腹腔镜手术治疗卵巢囊肿蒂扭转的临床价值.方法:回顾性分析我院2001年2月至2008年10月间接受腹腔镜诊治的43例卵巢囊肿蒂扭转患者的临床资料.结果:43例患者平均年龄26.6岁,有腹痛病史41例,其中急性腹痛27例,伴恶心、呕吐21例.34例行腹腔镜下患侧附件切除术,9例行腹腔镜下患侧卵巢囊肿剥出术.所有病例均在腹腔镜下顺利完成手术治疗,平均手术时间65.0±16.5分钟,术中出血2-150 ml,中位出血量10 ml,无术时术后并发症发生.术后病理诊断卵巢成熟性畸胎瘤34例(79.1%),卵巢单纯囊肿3例(7.0%),卵巢粘液性囊腺瘤2例(4.7%),卵巢甲状腺肿1例(2.3%),卵巢巧克力囊肿1例(2.3%),副中肾管源性囊肿(卵巢冠囊肿)1例(2.3%),组织出血梗死不能辨认1例(2.3%).术后平均肛门排气时间27.3±11.4小时,术后平均放置尿管时间11.2±9.5小时,术后平均住院时间4.2±1.3天.结论:腹腔镜诊治卵巢囊肿蒂扭转具有及时准确、创伤小、出血少、术后恢复快等优点.     

Value of MRI in Characterizing Adnexal Masses

Magnetic resonance imaging (MRI) increases the specificity of imaging evaluation for adnexal masses, especially when they are indeterminate on ultrasound, very large or when further imaging is required to establish tissue characteristics. This article is a pictorial essay describing the value of MRI in characterizing adnexal masses.     

Evaluation of Positioning Devices for Optimization of Outcomes in Laparoscopic and Robotic-Assisted Gynecologic Surgery

In this review, we evaluate techniques, devices, and equipment for patient positioning and their effect on patient outcomes, such as cephalad slide and neuropathy, in laparoscopic and robotic-assisted gynecologic surgery. We conducted a systematic review by searching MEDLINE, Embase, and Cochrane Library for relevant articles published over a 15-year period. Study selection, data extraction, and quality assessment were performed by 2 reviewers independently. Seven articles, including 3 randomized controlled trials and 4 case series, were included in our analysis. Four studies evaluated cephalad patient slide. In 2 randomized controlled trials (n?=?103), the mean slide with various devices (i.e., memory foam, bean bag with shoulder braces, egg crate, and gel pad) ranged from 1.07 ± 1.93 cm to 4.5 ± 4.0 cm. The use of a bean bag with shoulder supports/braces was associated with minimal slide, with a median slide of 0 cm (range, 0–2 cm) in a retrospective series and with mean slide of 1.07 ± 1.93 cm in a randomized controlled trial (vs memory foam). No conclusive effect of body mass index on slide could be identified. Five studies evaluating the incidence of neuropathy found an overall incidence of 0.16% and no differences among slide-preventing devices. The minimal slide described across studies supports the conclusion that any of the currently used devices and techniques for safe patient positioning are within reason. The low overall incidence of neuropathy is also reassuring. Best evidence recommendations cannot be made for a specific device or technique; our findings suggest the importance of strict adherence to the basic tenets of safe patient positioning to minimize slide and prevent nerve injury.